# Situation: A 52-year-old man with epilepsy is admitted to the medical ward for evaluation of breakthrough seizures. He takes phenytoin 100 mg by mouth three times daily. He has been eating poorly for a month. While lying in bed, he suddenly stiffens and then jerks all four limbs. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630522  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 52-year-old man with epilepsy is admitted to the medical ward for evaluation of breakthrough seizures. He takes phenytoin 100 mg by mouth three times daily. He has been eating poorly for a month.

While lying in bed, he suddenly stiffens and then jerks all four limbs. Which action should the nurse take?

## 보기

1. Leave to get the suction machine from the utility room
2. Insert a padded tongue blade between his teeth
3. Turn him onto his side and clear hard objects away **✔ 정답**
4. Hold his arms and legs firmly to prevent injury

**정답: 3**

## 해설

During a tonic-clonic seizure the nurse stays with the client, calls for help, notes the time, and protects him from injury. Turning him onto his side lets secretions drain and keeps the airway open, and hard objects are moved away. Nothing is put into the mouth, and the client is not restrained.

## 심화 해설

Core action during a tonic-clonic seizure
The client suddenly stiffens (tonic phase) and then jerks all four limbs (clonic phase), which is a generalized tonic-clonic seizure. During the seizure itself, the nurse cannot stop the electrical discharge in the brain; the nursing priorities are to protect the airway and to prevent injury until the seizure ends. The correct action combines both: turning the client onto his side and moving hard objects out of the way. Side-lying lets saliva and vomitus drain out of the mouth instead of into the airway, and it lets the relaxed tongue fall forward rather than back against the pharynx. Clearing hard objects removes the things he could strike while his limbs are jerking.

What the nurse does around that action
Seizure care is a short bundle of actions done at the bedside. The nurse stays with the client and calls for help rather than leaving, notes the time the seizure begins so its duration can be reported, loosens tight clothing at the neck, and protects the head with something soft if he is not already on a mattress. Side rails, if used, are padded. After the convulsion stops, the nurse keeps him side-lying in the recovery position, checks breathing and oxygen saturation, suctions if secretions remain, and observes the postictal state. A seizure lasting about 5 minutes or longer, or repeated seizures without recovery in between, is treated as status epilepticus, a medical emergency.

Why the other actions are unsafe
Each distractor reflects an old or instinctive response that actually causes harm. Nothing is ever put into the mouth during a seizure. The jaw clenches with great force, so a tongue blade or finger can break teeth, cut the mouth, be bitten, or become a foreign body that blocks the airway. Holding the arms and legs firmly does not shorten the seizure; pushing against strong muscle contractions can cause fractures, dislocations, and soft tissue injury. Leaving the room to get equipment abandons the client at the moment his airway is most at risk; the nurse calls for help and keeps suction set up in advance for clients on seizure precautions.

| Action | Safe? | Reason |
| --- | --- | --- |
| Turn to side, clear hard objects | Yes | Opens the airway, drains secretions, prevents injury |
| Insert tongue blade | No | Broken teeth, oral injury, airway obstruction |
| Restrain limbs | No | Fractures, dislocations, soft tissue injury |
| Leave to get suction | No | Client left alone during airway risk |

Link to the situation
This client is on phenytoin and has been eating poorly for a month, so his breakthrough seizures may be related to his drug therapy, his nutrition, or his serum level. Those questions are explored after the seizure. During the event, the nurse's job does not change: airway, safety, timing, and observation. Observations worth recording include where the movements started, how the seizure spread, how long it lasted, whether he was incontinent, and how long it took him to become oriented afterward.

Exam takeaway
Key point For any question asking what to do during a seizure, choose the option that stays with the client, positions him on his side, and protects him from injury. Reject any option that puts something in the mouth, restrains the limbs, or leaves the client alone.

## 임상 시나리오

Bedside Care in a Tonic-Clonic SeizureAirway and injury prevention first
Stay with the client, call for help, and note the time the seizure starts. Turn him onto his side so secretions drain and the tongue falls forward, and move hard objects away.

Loosen tight clothing, cushion the head, and pad side rails if used. After the seizure, keep him in the recovery position, check breathing and oxygen saturation, and observe the postictal period.

A seizure lasting about 5 minutes or more, or repeated seizures without recovery, is status epilepticus and needs emergency treatment.

CautionNever insert a tongue blade or any object into the mouth, and never restrain the limbs. Both cause injury and neither stops the seizure.

## 핵심 개념

- **Tonic-clonic seizure** — A generalized seizure with a stiffening (tonic) phase followed by rhythmic jerking (clonic) of the limbs and loss of consciousness.
- **Postictal state** — The period after a seizure marked by drowsiness, confusion, headache, or weakness while the brain recovers.
- **Status epilepticus** — A seizure lasting about 5 minutes or longer, or repeated seizures without recovery between them; a medical emergency.
- **Seizure precautions** — Measures such as padded side rails, suction and oxygen at the bedside, and a low bed used for clients at risk of seizures.

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